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Making Cents of Cancer Coverage: How Providers Can Support
Behavioral Health Patients in Financing Cancer Care
Comprehensive Cancer Control Webinar SeriesOctober 17, 2017 2:00 PM EDT
• Jointly funded by CDC’s Office on Smoking & Health & Division of Cancer Prevention & Control
• Provides resources and tools to help organizations reduce tobacco use and cancer among people with mental illness and addictions
• 1 of 8 CDC National Networks to eliminate cancer and tobacco disparities in priority populations
Free Access to…Toolkits, training opportunities, virtual communities and other resourcesWebinars & Presentations
State Strategy Sessions
Community of Practice
#BHtheChange
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Community of Practice participating organizations
• Assets, Incorporated, Anchorage, AK• Edgewater Systems for Balanced Living, Gary, IN• Health Solutions, Pueblo, CO• Integral Care, Austin, TX• Meridian Health Services, Muncie, IN• Mental Health America of Los Angeles, Long Beach, CA• Northwest Alabama Mental Health Center, Jasper, AL• Oakland County Community Mental Health Authority, Auburn Hills, MI• Saginaw County Community Mental Health Authority, Saginaw, MI• Shiawassee County Community Mental Health Authority, Owosso, MI• West Texas Centers for MHMR, Big Spring, TX
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Webinar Technology • Webinar is being recorded. All participants
will be placed in “listen-only” mode. • You must dial-in into the conference line and
input your unique passcode. • Submit questions using the Q & A pod. • Tech Support can be reached at 1-888-523-
8445.
3
Agenda
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Laura Hale – American Lung Association Shannon Morris – American Cancer
Society Dr. Diane Beneventi – MD Anderson
Cancer Center Q & A Wrap-up
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Laura Hale is a Program Manager for the American Lung Association. In her nationwide capacity, she provides expertise and technical assistance on tobacco cessation coverage issues to state programs and national partners. At the local level, Laura also oversees a smoke free multi-unit housing initiative in the nation’s capital, where she provides technical assistance for property managers seeking to end in-unit smoking. Laura studied sociology and women’s, gender, and sexuality studies at American University in Washington, DC.
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Tobacco Cessation Coverage Policy
October 17, 2017
Laura Hale Program ManagerAmerican Lung Association
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• Background• Types of Healthcare Coverage
and Requirements • Resources
Overview
FOR INTERNAL USE ONLY DO NOT DISTRIBUTE. Confidential and proprietary property of the American Lung Association, all rights reserved. 8
Background
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Background
• 3 Types of Counseling • Individual (face-to-face)• Group • Phone
• 7 Medications• 5 NRTs (Gum, Patch, Lozenge, Nasal
Spray, Inhaler)• Bupropion • Varenicline
Comprehensive Benefit
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Background
• Cost Sharing • Prior Authorization • Duration Limits • Yearly or Lifetime Limits • Dollar Limits • Stepped Care Therapy • Required Counseling
Common Barriers to Access Care
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Background
In 2015: • 68 percent of smokers wanted
to quit • 55.4 percent had tried to quit • Half received advice to quit
from a provider • Only 1/3 of smokers who tried
to quit used an evidence-based cessation treatment
• Only 1 in 10 smokers had quit successfully
Quitting Tobacco
FOR INTERNAL USE ONLY DO NOT DISTRIBUTE. Confidential and proprietary property of the American Lung Association, all rights reserved. 12
Types of Healthcare Coverage: Cessation Coverage Requirements
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Types of Health Coverage
• Private/Commercial • Group (employment-based)• Individual Market (direct
purchase)• Government
• Medicare• Medicaid• Other government (VA, Tri-Care,
etc.)
General Overview
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Types of Health Coverage
• Population prior to Medicaid expansion
• Low-income or some other “needy” group
• Eligibility criteria vary by state • Some federal requirements • Program administered by the
state • Combination of Federal and
State funding (FMAP)
Medicaid – Standard/Traditional
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Cessation Coverage
• Section 2502 of the Affordable Care Act (ACA) removed tobacco cessation medications from the exclusions list.
• Counseling not addressed. • Many States are still not covering all
7 Food and Drug Administration (FDA)-approved medications.
• Allows states to still charge a co-pay.
Standard Medicaid – Medications Requirement
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Cessation Coverage
• 2010 ACA requirement • All pregnant women on Medicaid
have access to all treatments with no cost sharing.
• Written into the Law- ACA Section 4107
• Includes all FDA-approved pharmacotherapy and counseling
Medicaid – Pregnant Women
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Types of Health Coverage
• Covers all individuals up to 138 percent of the Federal Poverty Level (FPL)
• 138 percent of FPL is $16,643 for an individual and $33,948 for a family of four
• Federal government pays for most of the cost
• Must cover the Essential Health Benefits (EHB)
• Expansion is optional for states
Medicaid expansion
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Types of Health Coverage
• Affordable Care Act Impact • Individual Marketplaces • Rating Rules • Essential Health Benefits • Premium Assistance (100 - 400
percent of the Federal Poverty Level)
• Cost Sharing Subsidies (Up to 250 percent of the Federal Poverty Level)
Private Coverage – Exchange/ Marketplace
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Types of Health Coverage
• Employers and plans make decisions • Can be fully insured or self- insured • Covers the largest segment of the
population • Trend towards self-insured plans • Geography Matters
• Single State vs. Multi-State Employer • Decisions made at corporate headquarters • Plan is based on the headquarters state
Private Insurance – Employer Sponsored
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Types of Health Coverage
Fully Insured Plans > Premium paid to a
insurer (typically split between employee and employer)
> Health insurer (company assumes the risk)
> Regulated by State Insurance Commissioner
Private Insurance – Fully Insured vs. Self Insured
Self Insured Plans – Employees will still pay a premium – Employer assumes the risk for the care – Employer determines what benefits to
cover – Frequently a health plan administers
the plan – Regulated by Department of Labor
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Types of Health Coverage
This Requirement> Almost all private plans > Plans sold in the exchanges > Small group plans > Individual plans > Medicaid expansion plans
ACA Preventive Services Requirements
Difference Requirements – Medicare – Standard Medicaid
Plans – Grandfathered Plans
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Types of Health Coverage
• ACA requires most plans to cover a minimum set of benefits: the Essential Health Benefits(EHB). The types of plans include: Private Plans, Exchange plans and Medicaid expansion plans.
• Includes the Preventive Services requirement.
Essential Health Benefits
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Cessation Coverage
• ACA requires most private plans, including any plan sold on the exchange and Medicaid Expansion plans, to cover without cost-sharing all services given an ‘A’ or ‘B’ grade by United States Preventive Services Task Force (USPSTF).
• Tobacco Cessation receives an ‘A’ grade
ACA Preventive Service Requirement
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Cessation Coverage
• On May 2, 2014 the Departments of Labor, Treasury and Health and Human Services issued a FAQ guidance on how the tobacco cessation recommendation should be implemented.
• Tobacco Cessation Guidance • At least 2 quit attempts per year, with each quit
attempt including:• No cost-sharing*• No prior authorization• At least 4 sessions of individual, group and phone
counseling• At least 90 days of all FDA-approved smoking
cessation medications, when prescribed
Cessation Guidance FAQ
Q5*cost-sharing prohibited by law: Patient Protection and Affordable Care Act, 42 U.S.C. § 18022 (2010)
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Cessation Coverage
• In September 2015, the USPSTF updated their recommendation, reaffirming the “A” grade for tobacco cessation.
• Found that both counseling and pharmacotherapy are effective to help smokers quit.
• States are responsible for implementation for private plans.
September 2015 USPSTF Updated Cessation Recommendation
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• Studies have suggested that many private plans in the exchanges are not covering all cessation treatments and in some cases are imposing cost-sharing and other barriers.
• Information on coverage is often conflicting and confusing
• Some states are reaching out to large private employers to improve coverage.
• Some states have reached out to their Insurance Commissioner to ask for a bulletin or consumer alert clarifying what needs to be covered.
Cessation Coverage
What does it mean?
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Types of Health Coverage
• Health coverage for people over 65• Funded by the federal government and
member premiums • There are 4 Parts
• A: Hospitalization • B: Outpatient care• C: Medicare Advantage • D: Prescription Drug
• National Coverage Determinations
Medicare
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Cessation Coverage
• Coverage Includes: • Group and Individual Counseling (4
sessions per quit attempt; 2 quit attempts per year)
• Medications (Part D Plans) • NRT Nasal Spray • NRT Inhaler • Bupropion • Varenicline
• Cost-sharing and other barriers may apply
Medicare Tobacco Cessation Coverage
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Types of Health Coverage
• Tricare – Military and Military Families
• Veteran's Healthcare (VA) • Still a sizable population that is
uninsured • States that haven’t expanded
Medicaid• Premiums are still too expensive • Undocumented immigrants
Other Types of Health Coverage
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Cessation Coverage
• Variation in insurance premiums based on a policyholder’s tobacco use
• Also referred to as tobacco premiums, premium/rate differentials, non-smoker discounts
• ACA allows surcharges of up to 50 percent for tobacco use in group & individual markets (subsidies do not apply to tobacco surcharges)
• States can limit or prohibit the surcharge
Tobacco Surcharges
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Resources
Lung.org/Cessation TA
• Listservs• Local Lung Association • Resource Library: www.lung.org/cessationta• ACA Toolkit: www.lung.org/acatoolkit• Cessation Guidance Toolkit:
www.lung.org/cessationguidance• Working with healthcare enrollment assistors:
www.lung.org/assistorstoolkit• Technical assistance
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Shannon Morris, Service Delivery Senior Manager at American Cancer Society’s National Cancer Information Center (NCIC), supports specialists working directly with constituents who have been touched by cancer to provide lifesaving services such as lodging, transportation, health insurance and cancer information. She provides oversight and guidance to several ACS programs and initiatives including the Health Insurance Assistance Service (HIAS) which provides critical information regarding health insurance options to cancer patients, survivors and those concerned about a possible diagnosis. Shannon started her career with ACS over 13 years ago, and has had a variety of roles including Patient Navigator, Cancer Information Specialist and was one of the founding members of the Health Insurance Assistance Service.
ACS Resources and the Health Insurance Assistance Service (HIAS)
Background on HIAS
Health Insurance Assistance Service Goals• Provide consistent and unbiased information about health insurance
options to over 65,000 callers since HIAS was created in April of 2005
• Document patient cases that illustrate barriers to insurance Adequacy, Availability, Affordability and Administrative Simplicity
• Share patient stories and advocate for public policy change
• Track implementation of the Affordable Care Act
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HIAS Videohttps://www.youtube.com/watch?v=8oZ9v2Be0Ls
Who is calling?• No single caller profile
• Three main groups: Uninsured
Insured facing a transition
Insured with affordability and/or adequacy issues
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This is HIAS caller “Raina”who had insurance whenshe faced thyroid cancer,but still faced financial debtthat resulted in her medicalbills being turned over tocollection agencies.
Service Area - English & Spanish Language
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FLORIDA
MISSISSIPPI
WESTVIRGINIA
RHODE ISLAND
WASHINGTON
OREGON
IDAHO
MONTANA
WYOMING
SOUTHDAKOTA
NEBRASKA
MINNESOTA
WISCONSIN
ILLINOIS INDIANAOHIO
MISSOURI
COLORADO
UTAH
NEVADA
CALIFORNIA
ARIZONA
NEW MEXICOOKLAHOMA
ARKANSAS
KENTUCKY
VIRGINIA
TEXAS
MASSACHUSETTS
GEORGIA
ALABAMA
SOUTHCAROLINA
NORTH CAROLINATENNESSEE
PENNSYLVANIA
MARYLAND
NEW JERSEY
NEW YORK
CONNECTICUT
VERMONT
NEW HAMPSHIRE
MAINE
DELAWARE
LOUISIANA
IOWA
WASHINGTON, D.C.
MICHIGAN
ALASKA
HAWAII
KANSAS
How HIAS Helps
41 41
Patient, family member, friend, or healthcare professional calls 800-227-2345. NCIC specialist refers to HIAS for
health insurance information
HIAS PRS receives request, performs assessment, probes to understand
referral, explains HIAS, clarifies what they have heard to see how they can
help.
HIAS PRS gathers details such as DOB, health insurance history, income, etc. to
prepare for discussion of available health insurance options.
HIAS PRS provides health insurance options and discusses insurance questions and issues.
HIAS PRS uses Society resources to help with other needs the constituent might have (e.g. questions about treatment options, where to locate a treatment
center, assistance with transportation or support)
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Details of the Service • Help callers obtain and maintain private health insurance, find
solutions to allow for this
• Provide information, not advice
• Careful, complete documentation
• When callers cannot afford private health insurance, educate on ways to seek medical care as an uninsured person
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Program Description• This program provides service to cancer patients, people with symptoms,
and cancer survivors (or someone calling on their behalf) who are struggling with health insurance-related problems.
• This program can assist in identifying health insurance options for which you might be eligible, and advocating for large-scale public policy change.
• While this program does not provide financial assistance to patients, it helps patients navigate insurance-related issues.
• This program is also able to discuss options with someone's current coverage and situation, such as insurance appeal processes and co-pay relief organizations. In addition, the Health Insurance Assistance Service is interested in learning patient stories for advocacy purposes.
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How We Help Future ConstituentsWork with ACS CAN to identify disparities • Legislative Action
• BCCEDP/BCCPTA• Hearings
Media Attention• CBS News• ABC News• CNN.com• New Work Times• Wall Street Journal• National Public Radio• Consumer Reports• Self Magazine• USA Today• US News and World
Report• Los Angeles Time• Washington Post• Associated Press• TIME Magazine• A2C Campaign• PBS Documentary• AARPAnd HIAS data published in the Journal of Cancer Education!
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Historical Volume
2015
3,221 Cases
2016
2,684 Cases
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What is out of scope for HIAS?
HIAS does not assist with the following:
• life, dental, supplemental and vision insurance• constituents seeking health insurance information from U.S. territories,
such as Puerto Rico, the U.S. Virgin Islands and Guam• patients currently receiving ongoing assistance
from Medicare or Medicaid programs (someone seeking a Medicare supplement is not eligible; a patient losing Medicare or Medicaid is eligible)
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Tools and ResourcesRefer constituents to 800-227-2345
• A specialist will assess and address needs 24/7• One of 8 HIAS PRS will contact the constituent if
there is a health insurance need• Available Monday – Friday, 7:00 a.m. – 6:00 p.m.
CT
ACS Resources
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National Cancer Information Center (NCIC)
• Located in Austin Texas
• Over 500 staff in a variety of roles • Cancer Information Specialists• Cancer Resource Specialists• Patient Resource Specialists • Support Staff
• Quality, Reporting, Leadership, etc.
• Available 24 hours a day, 7 days a week
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ACS Programs• Road to Recovery
• Hotel Partners Program
• Reach to Recovery
• Look Good Feel Better
• Wigs
• Database of over 40,000 local and national resources
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National Resources Spotlight• Medication Assistance
• NeedyMeds• www.needymeds.org
• Partnership for Prescription Assistance (PPA)• www.pparx.org
• CancerCare• www.cancercare.org
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National Co-Pay Assistance Resources• HealthWell Foundation
• www.healthwellfoundation.org
• Good Days from CDF (formerly Chronic Disease Fund)• www.mygooddays.org
• Patient Advocate Foundation (PAF)• http://www.patientadvocate.org
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Dr. Diane Beneventi is an Assistant Professorin the Department of Behavioral Science atUniversity of Texas MD Anderson CancerCenter. She has served as a supervisor in theMD Anderson Tobacco Treatment Program forthe past five years and has been a licensedpsychologist for 17 years. She is also aCertified Tobacco Treatment Specialist.
Cancer Prevention & Control Platform
Tobacco Cessation Treatment Protocol and Outcomes at UT MD Anderson Cancer Center
Dr. Diane BeneventiAssistant Professor - Tobacco Treatment Program
Department of Behavioral ScienceThe University of Texas MD Anderson Cancer Center
[email protected] (V) 713-794-4730 (fax)
Cancer Prevention & Control Platform Need for Cessation
Intervention
Nearly 70% of smokers want to
quit
42% report a quit attempt in the past
12 months
Annually less than 3% success
Nicotine dependence should
be considered a chronic relapsing
disorder
Up to 14 attempts needed for some to
achieve success
Negative affect (symptoms of
depression negative mood) significantly predicts prevalence
and relapse
Tobacco Treatment Program (TTP)
• Mission: To evaluate and treat all MD Anderson Cancer Center patients, their cohabitants, employees, employee spouses and their dependents who self-report as current tobacco users or recent quitters
• Center of Excellence since 2006: • Outcomes• Research• Customer service
TTP Funding
• University of Texas MD Anderson Cancer Center receives funding from state appropriations as part of the Texas Master Settlement Agreement (MSA).
• This funding is then allocated to several service line items at the institution. The TTP is one of the beneficiaries of this funding mechanism.
TTP Comprehensive Approach: Evidence-Based, Outcomes-Driven
• Professional evaluation of tobacco use, assessment for depression, anxiety, insomnia, alcohol use, etc.
• 6 – 8 intensive therapy sessions
• Proactive medication management using 1st line, 2nd line, and off-label medications
• Identification & referral for psychiatric comorbidities
• Long term follow-up every 3 months for up to a year
• Multidisciplinary team approach to maximize patient outcomes
Referral TrackingAverage Number of Referrals per Day by Week April 30, 2012 through August 31, 2016
Average number of referrals per dayProvider referrals = 11.1Automatic EHR referrals = 45.0 – 304% increaseTransition = 29.4Epic Referrals = 48.1
Providerreferrals
Automatic EHR referralsEpic referrals
Transition
Average Number of Patients Per Month2010 – 2016 Referral Tracking
48
63
81
95
0102030405060708090
100
Provider Referrals Automatic Referrals Phone Option EpicSep 2010 – Jul 2012 Aug 2012 – Apr 2013 May 2013 – Feb 2016 May 2016 – Aug 2016
31% increase
29% increase
17% increase
98% overall
increase
EPIC Screen Shot
Medical History Screen Shot
Smoking Status Screen Shot
Assessment Screen Shot
Assessment Review Screen Shot
Cancer Prevention & Control Platform A Proactive Treatment Model Operating
System-Wide within MD Anderson
• Referral to the TTP is automatic and not provider dependent
• Automatic identification of smokers and recent quitters (within12 months)
on the EHR triggers action from the TTP staff
• Four Available Treatment options
• Response/triage is made within 3 business days
Cancer Prevention & Control Platform Treatment Options for Every
Patient
Self-Help & follow-up
Every patient is called (4X). If not reached, materials are sent & followed in 3 monthsSelf-Help Packet includes tip guide, local and web resources and medication information
Motivational Enhancement
• All reached patients receive a motivational intervention on first call from bachelor level support staff to assess smoking status, readiness to quit and patient preferences
• Can be triaged to counselor, scheduled for in-person or phone-option or receives self-help plus 3 mos. follow-up. All patients accepted regardless of motivation level.
Phone Only
• Telephone counseling only, similar to in-person, but no medication consultation with program physician, or program provided medication. Keeps same counselor, schedules follow-ups as in-person
• Also receives all self-help information and offer to send information or consult with their physician for Rx
Comprehensive
Highly individualized treatment done by Masters level professionals (assigned at consult)Address motivation, cancer care, psychosocial and financial stress, mental health concerns.Pharmacotherapy-full range of monotherapies; combinations & on-going management/change
TTP Overview
69
Cancer Prevention & Control Platform
47% 48% 47% 48%
41% 42%37% 34%
0%
10%
20%
30%
40%
50%
60%
EOT (3 Month) 6 Month 9 Month 12 MonthTQL Respondent-Only Intent-to-Treat
Cessation Rates 2012 – 2015
Patient Characteristics FY-2014: Psychiatric Comorbidities
Cancer Prevention & Control Platform
Tobacco Use and Behavioral Health Disorders Cont.
49.8% 48.5% 46.6%
45.5% 48.1% 46.8%
0%
10%
20%
30%
40%
50%
60%
EOT (3 Month) 6 Month 9 MonthNo Dx 1 Dx 2+ Dx
Cumulative Cessation Rates
Cancer Prevention & Control Platform
Program Clinical Staff
Counseling Team – Diane Beneventi, PhD
Leanne Witmer, MA LPCS – Sr. Counseling Associate
Chinyere Eigege, MSW – Counseling Associate
Mark Evans, MSW, LCSW – Sr. Counseling Associate
Nancy Huang, M.A., LPC – Sr. Counseling Associate
Jummy Iyiola, M.A., LPC – Counseling Associate
Melissa Macomber, M.A., LPC – Counseling Associate
James Staley, M.A., LPC – Counseling Associate
LaDonna Malone,MA., LPC-Counseling Associate
Elham Babaie, MA.,LPC Counseling Associate
John Najera, MA., LPC-Counseling Associate
Medical Team
Maher Karam-Hage, MD
Roberto Gonzalez, MD
Sheila Kitaka, PA – Physician Assistant
Rosario Wippold, RN, M.P.H. – Research Nurse
Program Support Staff
Joy Neal – Senior Administrative Assistant
Research Team
Isamar Ortiz – Research Assistant
Kaylon White– Research Assistant
Valeria Velazques-Research Assistant
Kathleen Quick – Research Coordinator
Rory Crossin-Research Coordinator
Danielle Grbavac-Research Coordinator
Monica Tortolero – Sr. Research Coordinator
Data Team
Rudel Rymer – Senior Applications Systems Analyst
Bryce Reinesch – Associate Programmer Analyst
EndTobacco Team
Jennifer Cofer, MPH, CHES - Director
Alex Hurst, MHA - Program Manager
Andrea Antwi, MPH – Program Coordinator
Acknowledgements
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